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Letter from Mike Farrar, NHS Confederation

26 February 2003

John Chisholm
Chairman
General Practitioners Committee

Dear John

I am delighted to write to you setting out the details of the new GMS contract following the outcome of our negotiations over the past 16 months. As in April 2002, I will summarise the agreements we have reached in this covering letter. Details of the new GMS contract are set out in the document Investing in General Practice - The New General Medical Services Contract.

The proposed new contract represents a landmark in the development of UK general practice. It provides demonstrable benefits to GMS GPs, to primary healthcare professionals, to the NHS and most importantly to patients. These, coupled with the largest sustained investment in primary care the NHS has ever made, will create the platform for a step change in improved health and health services, boosting morale and creating greater and fairer rewards for GPs.

The new contract agreement will be accompanied by investment across the UK of over £8.0bn over the coming three years. This means an average uplift in investment of 11 per cent per year, each year for the next three years. In investment terms, this deal allows for faster and more substantial proportionate growth in the primary care sector than any other area of the NHS. Within this, GPs will have the boost of significant new money for practice infrastructure (IM&T, premises and workforce); money to improve their working lives (out-of-hours arrangements, career development, appraisal, education and training, pensions etc); improved remuneration commensurate with their professional roles and responsibilities; and contribution to a reformed NHS. They will also be able to take advantage of significant additional earnings opportunities if they contribute to the expansion of the primary care sector, by developing the range of services available to patients in the community.

In summary, we have agreed:
- details of all the key aspects of the contract including pricing that builds on the framework agreement and its acceptance by the profession

- movement to a practice-based contract with investment for infrastructure and running costs upfront via a global sum, distributed fairly in line with the weighted needs of the patients to reflect GP and practice workload and complexity

- a system, through the quality and outcomes framework, for rewarding GPs and their staff for the volume and quality of the work done. This framework is designed on a strong evidence base, to reward improvements in clinical and organisational standards, and patient experience, whilst operating within a high trust monitoring system confirming GPs’ professional autonomy to determine how to organise their work to achieve these standards. This framework will recognise and reward the GP’s commitment to personal care, continuity of care as evidenced by good chronic disease management, and greater responsiveness to acute single episodes of care through maintenance of progress on greater choice and speed of access

- a platform for allowing management of workload within individual practices (through the shift of responsibility for out-of-hours care, the introduction of a changed system for managing patient allocations, the development of options to allow practices to withdraw from ‘additional’ service provision, typically, at times of workload pressure, the development of GP career planning, allowing GPs to take sabbaticals from practice in order to develop new skills or to replenish their energy and commitment, the promotion of multi-disciplinary working at practice level, and through a range of demand management initiatives and proposals). This contrast ensures that new work is accompanied by new resources. Beyond 2005/06, this will be backed up through a process of workload review

- a strategy to expand and develop the primary care sector in order to allow practices to have the needs of their patients met within community and primary settings rather than hospital, as a consequence of expanded and direct access to more specialised advice and knowledge. This will also enable those practices with ambitions to develop their range of practice-based services to provide ‘enhanced’ services from within the protected resource stream in the recent budget allocations

- a major overhaul and modernisation of the infrastructure and management processes involved in the provision of general practice (greater investment in IM&T, premises that are fit-for-purpose, greater equity of employment conditions with the rest of the NHS family, support for the development of better practice management, investment in family-friendly workforce policies, improvements to the existing pension scheme and a major drive to reduce further the bureaucracy involved in management and financial flows within general practice)

- a programme of financial support to help manage the transition from the old to the new contract and a sensible iteration of change, in line with the legislative timetable in the four countries, which will help practices and PCOs safely understand, prepare for and exploit the new arrangements, starting in April 2003.

This substantial package of investment and improvement in primary care, with significant earnings opportunities for GPs, provides an answer to those GPs who made it clear in your original survey that primary care could not go on without significant additional investment and that a complete overhaul of the existing contract was necessary to boost the morale of GPs, and address the problems of recruiting a new workforce and retaining the existing one.

This package is designed to support practices from all parts of the existing spectrum – whether inner city or rural and remote, single-handed or large group, well staffed or currently understaffed. This is because the new contract is fairer in the allocation of resources, allows for workload variation and management, recognises and rewards quality and outcomes, not inputs, and puts professional self-esteem and autonomy at the heart of delivery.

As to its benefits to the wider primary care workforce, this contract recognises and reinforces the multi-disciplinary nature of primary care. It creates opportunities for nurses, allied health professionals, pharmacists and managers to gain from the practice-based contract, much of which will require them to be central to its delivery. It will create better corporate and clinical governance models in primary care to ensure good human resource policies are followed through in practices and will establish incentives for greater investment in basic training and continuing professional development for key practice members.

For the patient, the benefits of the contract are equally clear. The patient experience of primary care will be assessed and will contribute to the income the practice receives, creating incentives for improvements in customer care and the development of expert patient schemes. Patients will be guaranteed to receive the range of services they currently get, but with expanded choice in some service areas, improved quality and outcomes and speed of access. In terms of choice of GP and services, patients will be able to access GPs as they currently do, but will receive better information from practices about services and service changes. In some cases, patients may be able to have a choice of practice in the case of some ‘additional’ and ‘enhanced’ services. For most patients, the major benefit should come in the anticipated improvements in primary care quality they receive and the greater investment in the IM&T and physical infrastructure within the practices they are registered with. This will, over time, reduce the need for hospital-based care for the diagnosis and treatment of most chronic disease.

There are also clear benefits in the deal for the wider NHS. The size, scale and scope of the investment in primary care, coupled with the incentives for practices to improve the quality and outcomes in treating acute and chronic health problems now enable a shift in the focus of resources and care to primary and community settings. GPs and their staff will have greater freedom to concentrate on the delivery of high quality primary care, enabling progress to be made on tackling health inequalities and reducing unnecessary secondary care demand by keeping more people fit and healthy. Good demand management and an expansion of the primary care workforce will allow practices more time to measure and maintain the health of their practice population. The new resource formula will enable a much fairer and equitable distribution of the resources for the primary care sector and the new mechanics of its allocation will keep the money in the local practice even if GP and other staff numbers reduce. This vision of primary care is supported by many GPs who have become frustrated by the old contract and see its replacement as vital to create new incentives and rewards for GPs.

Finally, for PCOs, the new contract enables them to have a better contractual relationship with their constituent practices. One that recognises the autonomy of the practices to deliver as they best see fit but also allows PCOs to provide support to them and to organise the structures around them to maximum effect (such as workload support, out-of-hours services, protected training and development time, strategic investment in premises and effective IM&T systems).

The deal we have agreed represents a major achievement for the NHS Confederation and the British Medical Association. Many of the things that a positive vote for this new contract would herald have been talked about but not been possible to deliver for a number of years now. I believe that GPs now have an opportunity to vote for a major programme of investment and improvement in primary care delivered through a modern, fair and principled contract. I am grateful to you and your team for all the hard work and effort that have gone into these negotiations and hope that GPs recognise the unprecedented scale of investment and commensurate earnings opportunities that will now flow.

Yours sincerely

Mike Farrar
Chair
NHS Confederation negotiating team